Investigation of the role of infusate properties related to midline catheter failure in an ovine model

Abstract

Purpose Infusate osmolarity, pH, and cytotoxicity were investigated as risk factors for midline catheter failure. Methods An experimental, randomized, controlled, blinded trial was conducted using an ovine model. Two 10-cm, 18-gauge single-lumen midline catheters were inserted into the cephalic veins of sheep. The animals were divided into 6 study arms and were administered solutions of vancomycin 4 mg/mL (a low-cytotoxicity infusate) or 10 mg/mL (a high-cytotoxicity infusate), doxycycline 1 mg/mL (an acidic infusate), or acyclovir 3.5 mg/mL (an alkaline infusate) and 0.9% sodium chloride injection; or 1 of 2 premixed Clinimix (amino acids in dextrose; Baxter International) products with respective osmolarities of 675 mOsm/L (a low-osmolarity infusate) and 930 mOsm/L (a mid-osmolarity infusate). Contralateral legs were infused with 0.9% sodium chloride injection for control purposes. Catheter failure was evaluated by assessment of adverse clinical symptoms (swelling, pain, leakage, and occlusion). A quantitative vessel injury score (VIS) was calculated by grading 4 histopathological features: inflammation, mural thrombus, necrosis, and perivascular reaction. Results Among 20 sheep included in the study, the overall catheter failure rate was 95% for test catheters (median time to failure, 7.5 days; range, 3–14 days), while 60% of the control catheters failed before or concurrently (median time to failure, 7 days; range, 4.5–14 days). Four of the 6 study arms (all but the Clinimix 675-mOsm/L and acyclovir 3.5-mg/mL arms) demonstrated an increase in mean VIS of ≥77% in test vs control legs (P ≤ 0.034). Both pain and swelling occurred at higher rates in test vs control legs: 65% vs 10% and 70% vs 50%, respectively. The mean difference in rates of occlusive pericatheter mural thrombus between the test and control arms was statistically significant for the vancomycin 10-mg/mL (P = 0.0476), Clinimix 930-mOsm/L (P = 0.0406), and doxycycline 1-mg/mL (P = 0.032) arms. Conclusion Administration of infusates of varied pH, osmolarity, and cytotoxicity via midline catheter resulted in severe vascular injury and premature catheter failure; therefore, the tested infusates should not be infused via midline catheters.

Peripherally Inserted Central catheter iNnovation to reduce Infections and Clots (the PICNIC trial): a randomised controlled trial protocol

“… 10 Some manufacturer-funded, laboratory studies also suggest CHG coating has a role in the prevention of thrombosis development, with in vivo ovine models demonstrating a significant reduction in fibrin sheath development after 30 days in situ, in comparison with uncoated catheters (median 0.05 g (CHG) vs 0.7 g (uncoated)). 11 However, the effectiveness of CHG-coated PICCs to prevent thrombotic and infective complications has not been formally tested in clinical trials in humans.…”

Does the Midline Peripheral Intravenous Catheter Have a Place in Critical Care?

“…43 The location of the MC distal tip in the axillary vein may contribute to lower reported MC-associated phlebitis rates because of the higher blood flow in this area as compared with more distal vessels. 10,15,17 In their clinical review of the MC, Adams et al 15…”

“…They postulated that PIVC failure may be a function of dwell time and duration of exposure to the test infusates. 10…”

“…6,8,23,24,62 Once a VAD is placed either peripherally or centrally, it should be managed with the utmost care for prevention and early recognition and treatment of VAD-related complications. 4,7,8,10,23,55 Table 5 provides a summary of evidencebased peripheral intravenous access management. The Michigan Appropriateness Guide for Intravenous Catheters, published in 2015, provided a valuable summary of expert consensus on scenario-based VAD selection and placement according to patient need, duration of therapy, infusate, and duration of treatment.…”

“…This process is often used in an effort to avoid reportable hospital-acquired infections. 5,[7][8][9][10][11][12][13][14] Use of the midline catheter (MC) has undergone a resurgence because of the need to provide a long-term peripheral vascular access option that is not Background The goals of infusion therapy are to preserve vascular health and safely deliver needed treatment. Achieving these goals is challenging in critical care because of the complexity of the treatment required.…”